Healthcare Provider Details

I. General information

NPI: 1427225721
Provider Name (Legal Business Name): JACLYN L DODD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN L MONFORT PTA

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 W NORDALE DR
APPLETON WI
54914-1887
US

IV. Provider business mailing address

204 S HELEN ST
KIMBERLY WI
54136-1727
US

V. Phone/Fax

Practice location:
  • Phone: 920-990-0181
  • Fax:
Mailing address:
  • Phone: 920-819-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1362-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: